Music and Disorders of Consciousness

An introduction to the use of music for diagnosis and treatment of people with traumatic brain injury

REBECCA MENZA, RN, MS, NP, PhD(c) Zuckerberg San Francisco General Hospital University of California: San Francisco

MUSIC IN THE BRAIN and in the MIND

•  Auditory Cortex (including the temporal lobe) •  Prefrontal Cortex; Anterior Cingulate •  Limbic system: Nucleus Accumbens, Amygdala, Hippocampus, Thalamus, hypothalamus •  Cerebellum •  Occipital lobe

Illustration: Christine Daniloff/MIT from http://news.mit.edu/2015/neural-population-music-brain-1216

A: Amygdala AC: Auditory Cortex VM: Ventromedial Cortex H: Hypothalamus

Proposed psychoneurobiological response to music, an application of Damasio’s Theory of Emotion, Feeling and Consciousness with Florence Nightingale’s Theory of the Nursing and the Environment, adapted from Hannah Damasio, Damasio, 1994.

Music responders (may) have better outcomes

Castro, M., Tillmann, B., Luaute, J., Corneyllie, A., Dailler, F., Andre-Obadia, N., Perrin, F. Boosting Cognition With Music in Patients with Disorders of Consciousness. Neurorehabilitation and Neural Repair 2015, 29 (8) 734-42

+

-

Music (may) boost cognition

OFN, OFN, OFN, SON, OFN, SON,

OFN, OFN….

Castro, M., Tillmann, B., Luaute, J., Corneyllie, A., Dailler, F., Andre-Obadia, N., Perrin, F. Boosting Cognition With Music in Patients with Disorders of Consciousness. Neurorehabilitation and Neural Repair 2015, 29 (8) 734-42

Repeated Exposure to Preferred Music is Associated with higher GCS and lower Quantitative EEG (δ+θ/α+β)

Sun, J., Chen, W. Music Therapy for Coma Patients: Preliminary Results. European Review for Medical and Pharmacological Sciences. 2015; 19: 1209-1218

15-30 min 3x/day

Repeated Exposure to Preferred Music is Associated with higher GCS and lower Quantitative EEG (δ+θ/α+β)

Sun, J., Chen, W. Music Therapy for Coma Patients: Preliminary Results. European Review for Medical and Pharmacological Sciences. 2015; 19: 1209-1218

p=.041

p=.038

15-30 min 3x/day

Pleasant Audio Stimulation on the Level of Consciousness of Coma Patients

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GCS by day Music (10 min/day preferred) Versus Control Condition

Music Control

music: 6.20 (+/- 1.4), control 6.23 (+/- 1.5) p= 0.937

2.29

music 9.49 (+/- 2.8) control 7.20 (+/- 2.6) P=.0001

P =.015

Rahimi, F., Saleh, K., Seidi, J. The effect of pleasant audio stimulation on the level of consciousness of comatose patient: a randomized clinical trial. Acta Medica Meditterranea 2019; 35: 985-989

Meaningful auditory stimulation: familiar voice

Tavangar H, Shahriary-Kalantary M, Salimi T, Jarahzadeh M, Sarebanhassanabadi M. Effect of family members' voice on level of consciousness of comatose patients admitted to the intensive care unit: A single-blind randomized controlled

trial. Adv Biomed Res 2015;4:106

Meaningful auditory stimulation: familiar voice

Tavangar H, Shahriary-Kalantary M, Salimi T, Jarahzadeh M, Sarebanhassanabadi M. Effect of family members' voice on level of consciousness of comatose patients admitted to the intensive care unit: A single-blind randomized controlled trial. Adv Biomed Res 2015;4:106

2.5

Disability Rating Scale Sensory Stimulation Assessment Measure

Glasgow Coma Score & Ranchos Los Amigos +/- Eye/Motor after music and family

No change in HR, BP, RR, and DID NOT AFFECT ICP, MAP, CPP

Disability Rating Scale Sensory Stimulation Assessment Measure

Glasgow Coma Score & Ranchos Los Amigos +/- Eye/Motor after music and family No change in HR, BP, RR, and

DID NOT AFFECT ICP, MAP, CPP

Baseline, 3 month and 6 month baseline: neuro-psych executive function (Frontal Assessment Battery) Motor Testing MRI (voxel based morphometry) Randomized Cross over design (AB/BA) 3 months music therapy vs standard

↑ Grey matter volume (GMV) in the right inferior frontal gyrus after music therapy intervention Correlates with ↑ cognitive improvement (set shifting)

Music Interventions for Acquired Brain Injury: Cochrane Database Systematic Review

Magee, WL, Clark, I, Tamplin, J., Bradt, J. Music interventions for acquired brain injury. Cochrane Database Syst Rev. 2017 Jan 20;1:CD006787.

Overall Communicatio

n 0.75 sd

Quality of Life

0.89 sd

Naming 9.79 units Aachen

Aphasia Test

Speech Repetition 8.90 units Aachen

Aphasia Test

Music Interventions for Acquired Brain Injury: Cochrane Database Systematic Review

Magee, WL, Clark, I, Tamplin, J., Bradt, J. Music interventions for acquired brain injury. Cochrane Database Syst Rev. 2017 Jan 20;1:CD006787.

Overall Communicatio

n 0.75 sd

Quality of Life

0.89 sd

Naming 9.79 units Aachen

Aphasia Test

Speech Repetition 8.90 units Aachen

Aphasia Test

Heine, Tillman, Hauet, et al. Effects of preference and sensory modality on behavioral reaction in patients with disorders of consciousness. Brain Injury. 2017: 31 (10):1307-11

Effect of Preferred Music on Agitation After Brain Injury

Park, S., Williams, R., Lee, D. Effect of preferred music on agitation after traumatic brain injury. Western Journal of Nursing Research. 2016 Apr;38(4):394-410.

Effect of Preferred Music on Agitation After Brain Injury

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1 1.2 1.4 1.6 1.8 2 2.2 2.4 2.6 2.8 3

ABS PREFERRED Music

Park, S., Williams, R., Lee, D. Effect of preferred music on agitation after traumatic brain injury. Western Journal of Nursing Research. 2016 Apr;38(4):394-410.

Effect of Preferred Music on Agitation After Brain Injury

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10

15

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1 1.2 1.4 1.6 1.8 2 2.2 2.4 2.6 2.8 3

ABS PREFERRED Music Heavy Metal (“Slayer,

Slipknot, Tool, Pantera, Ozzy Osbourne”)

Pop (“Chicago, Michael Jackson”)

Rap

Park, S., Williams, R., Lee, D. Effect of preferred music on agitation after traumatic brain injury. Western Journal of Nursing Research. 2016 Apr;38(4):394-410.

Effect of Preferred Music on Agitation After Brain Injury

0

5

10

15

20

25

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35

40

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50

1 1.2 1.4 1.6 1.8 2 2.2 2.4 2.6 2.8 3

ABS PREFERRED Music

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5

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1 1.2 1.4 1.6 1.8 2 2.2 2.4 2.6 2.8 3

ABS CLASSICAL Music

Park, S., Williams, R., Lee, D. Effect of preferred music on agitation after traumatic brain injury. Western Journal of Nursing Research. 2016 Apr;38(4):394-410.

(Classical)Music as a therapeutic intervention on an inpatient Neuroscience Unit

BASELINE SCORES

POMS Usual Care

(n=29)

Treatment Group (n=24)

p

Anxiety 3.5 (3.2) 7.5 (4.6) .001 Depression

2.9 (2.9) 5.6 (3.8) .005

Anger 2.5 (3.5) 3.0 (3.7) .612

Fatigue 6.5 (4.8) 9.3 (4.6) .036 Confusion 0.6 (2.8) 2.6 (3.3) .023 Vigor 4.6 (5.3) 2.8 (3.6) .141 Total 11.4+/- 15 26.4 +/- (16) .001

MEAN CHANGE SCORE

POMS Usual Care

(n=29)

Treatment Group (n=24)

P

Anxiety 0.5 (2.5) ↓4 (3.0) 0.000 Depression

0.52 (1.5) ↓2.8 (2.1) 0.000

Anger 0.36 (2.0) 1.1 (2.3) 0.23 Fatigue 0.81 (2.7) ↓2.8 (3.6) 0.03 Confusion 0.13 (2.2) 0.55 (1.7) 0.49 Vigor 0.52(2.7) 0.64 (2.8) 0.16 Total 1.26 (7.9) ↓12.4 (10) 0.000

Phipps, M., Carroll, D., Tsiantoulas, A. Music as a therapeutic intervention on an in patient neuroscience unit. Complement Ther Clin Pract. 2010 Aug;16(3):138-142. doi: 10.1016/j.ctcp.2009.12.001. Epub 2010 May 15.

(Classical) Music as a therapeutic intervention on an inpatient neuroscience unit

BASELINE SCORES

POMS Usual Care

(n=29)

Treatment Group (n=24)

p

Anxiety 3.5 (3.2) 7.5 (4.6) .001 Depression

2.9 (2.9) 5.6 (3.8) .005

Anger 2.5 (3.5) 3.0 (3.7) .612

Fatigue 6.5 (4.8) 9.3 (4.6) .036 Confusion 0.6 (2.8) 2.6 (3.3) .023 Vigor 4.6 (5.3) 2.8 (3.6) .141 Total 11.4+/- 15 26.4 +/- (16) .001

MEAN CHANGE SCORE

POMS Usual Care

(n=29)

Treatment Group (n=24)

P

Anxiety 0.5 (2.5) ↓4 (3.0) 0.000 Depression

0.52 (1.5) ↓2.8 (2.1) 0.000

Anger 0.36 (2.0) 1.1 (2.3) 0.23 Fatigue 0.81 (2.7) ↓2.8 (3.6) 0.03 Confusion 0.13 (2.2) 0.55 (1.7) 0.49 Vigor 0.52(2.7) 0.64 (2.8) 0.16 Total 1.26 (7.9) ↓12.4 (10) 0.000

Phipps, M., Carroll, D., Tsiantoulas, A. Music as a therapeutic intervention on an in patient neuroscience unit. Complement Ther Clin Pract. 2010 Aug;16(3):138-142. doi: 10.1016/j.ctcp.2009.12.001. Epub 2010 May 15.

The effect of music therapy on mood and anxiety-depression: An observational study of institutionalized patients with traumatic brain injury.

Guetin, S., Soua, B., Voiriot, G., Picot, M., & Herrison, C. The effect of music therapy of mood and anxiety-depression: An observational study of institutionalized patients with traumatic brain injury. Annals of Physical and Rehabilitation Medicine. 2009; 30-40

The effect of music therapy on mood and anxiety-depression: An observational study of institutionalized patients with traumatic brain injury.

Guetin, S., Soua, B., Voiriot, G., Picot, M., & Herrison, C. The effect of music therapy of mood and anxiety-depression: An observational study of institutionalized patients with traumatic brain injury. Annals of Physical and Rehabilitation Medicine. 2009; 30-40

The effect of music therapy on mood and anxiety-depression: An observational study of institutionalized patients with traumatic brain injury.

Guetin, S., Soua, B., Voiriot, G., Picot, M., & Herrison, C. The effect of music therapy of mood and anxiety-depression: An observational study of institutionalized patients with traumatic brain injury. Annals of Physical and Rehabilitation Medicine. 2009; 30-40

Take home

•  Perception/cognition of music may signal consciousness

•  The environment matters: sensory deprivation versus meaningful cognitive stimulus

•  Music as a therapeutic cognitive life line •  Personalized music as an equity-based

treatment •  Neuro-rehab can start day 1

What’s next

•  Examining differences in patient preferred music

•  Measuring effects of music listening on autonomic nervous system correlates

•  Developing protocols to offer preferred music to patients and families in acute hospitalization

•  Interested? Get in touch! Rebecca.Menza@ucsf.edu

References •  Castro, M., Tillmann, B., Luaute, J., Corneyllie, A., Dailler, F., Andre-Obadia, N., Perrin, F. Boosting Cognition With Music in Patients with Disorders of

Consciousness. Neurorehabilitation and Neural Repair 2015, 29 (8) 734-42

•  Davis, A., Gimenez, A. Cognitive Behavioral Recovery in Comatose Patients Following Auidotry Stimulation. Journal of Neuroscience Nursing. 2003. Aug; 35 (4): 202-9, 214.

•  Edlow, Chatelle, Spencer, Chu, Bodien, O'Connor, Hirschberg, Hochberg, Giacino, Rosenthal and Wu. Early detection of consciousness in patients with acute severe traumatic brain injury. Brain. 2017: 2399-2414

•  Guetin, S., Soua, B., Voiriot, G., Picot, M., & Herrison, C. The effect of music therapy of mood and anxiety-depression: An observational study of institutionalized patients with traumatic brain injury. Annals of Physical and Rehabilitation Medicine. 2009; 30-40

•  Heine, Tillman, Hauet, et al. Effects of preference and sensory modality on behavioral reaction in patients with disorders of consciousness. Brain Injury. 2017: 31 (10):1307-11

•  Kotchoubey, B., Pavlov, Y., Kleber, B., Music in research and rehabilitation in consciousness: psychological and neurophysiological foundations. Frontiers in Psychology. 2015; 6:1763.

•  Magee, WL, Clark, I, Tamplin, J., Bradt, J. Music interventions for acquired brain injury. Cochrane Database Syst Rev. 2017 Jan 20;1:CD006787. doi: 10.1002/14651858.CD006787.pub3.

•  Park, S., Williams, R., Lee, D. Effect of preferred music on agitation after traumatic brain injury. Western Journal of Nursing Research. 2016 Apr;38(4):394-410.

•  Phipps, M., Carroll, D., Tsiantoulas, A. Music as a therapeutic intervention on an in patient neuroscience unit. Complement Ther Clin Pract. 2010 Aug;16(3):138-142. doi: 10.1016/j.ctcp.2009.12.001. Epub 2010 May 15.

•  Rahimi, F., Saleh, K., Seidi, J. The effect of pleasant audio stimulation on the level of consciousness of comatose patient: a randomized clinical trial. Acta Medica Meditterranea 2019; 35: 985-989

•  Siponkoski, S. Martinez-Molina, N. Kuusela,…Sarkamo, T. Music therapy enhances executive functions and prestructural neuroplasticity after traumatic brain injury: Evidence from a randomized controlled trial. Journal of Neurotrauma. 2019: 23 Oct 2019https://doi-org.ucsf.idm.oclc.org/10.1089/neu.2019.6413

•  Sun, J., Chen, W. Music Therapy for Coma Patients: Preliminary Results. European Review for Medical and Pharmacological Sciences. 2015; 19: 1209-1218

•  Tavangar H, Shahriary-Kalantary M, Salimi T, Jarahzadeh M, Sarebanhassanabadi M. Effect of family members' voice on level of consciousness of comatose patients admitted to the intensive care unit: A single-blind randomized controlled trial. Adv Biomed Res 2015;4:106